Anaesthetic specialist registrars in Ireland: current teaching practices and perceptions of their role as undergraduate teachers

BACKGROUND AND OBJECTIVES

Teaching is an important responsibility of non-consultant hospital doctors. In Ireland, specialist registrars (SpRs) in anaesthesia are contractually obliged to teach medical students, other doctors and nurses. Both medical students and fellow non-consultant hospital doctors attribute between 30 and 40% of their knowledge gain to non-consultant hospital doctors.

METHODS

We carried out a confidential telephone survey of anaesthetic SpRs in Ireland regarding their current teaching practices and the perceptions of their role as undergraduate teachers. All the SpRs currently working in clinical practice in Ireland were eligible.

RESULTS

Fifty-five of the 79 (70%) SpRs responded to the questionnaire. Only 7 (12.7%) of the respondents said they had been well trained as a teacher. The majority of the respondents stated that they would attend a learning-to-teach course/workshop if one was available, and felt that such a course would improve their ability as a teacher. Only 8 (14.5%) agreed that adequate emphasis is placed on commitment to teaching in the assessment of SpRs, both by individual departments and by the College of Anaesthetists. Anaesthetic SpRs in Ireland spend a considerable amount of time each day teaching undergraduate medical students, the majority (68.9%) stated that they had inadequate time to prepare for teaching.

CONCLUSION

The majority of the respondents stated that they enjoy teaching, feel that they play an important role in undergraduate teaching but have inadequate time to prepare for teaching. An adequate emphasis is not placed on their commitment to teaching.

Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey

BACKGROUND AND OBJECTIVE

Adverse effects associated with difficult airway management can be catastrophic and include death, brain injury and myocardial injury. Closed-malpractice claims have shown prolonged and persistent attempts at endotracheal intubation to be the most common situation leading to disastrous respiratory events. To date, there has been no evaluation of the types of difficult airway equipment currently available in Irish departments of emergency medicine. The objective of this survey was to identify the difficult airway equipment available in Irish departments of emergency medicine.

METHODS

Departments of emergency medicine in the Republic of Ireland with at least one dedicated Emergency Medicine consultant were surveyed via telephone.

RESULTS

All of the departments contacted held at least one alternative device on site for both ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway (89%). The most common alternative intubating device was the surgical airway device (100%).

CONCLUSIONS

Irish departments of emergency medicine compare well with those in the UK and USA, when surveyed concerning difficult airway equipment. However, we believe that this situation could be further improved by training inexperienced healthcare providers in the use of the laryngeal mask airway and intubating laryngeal mask airway, by placing greater emphasis on the ready availability of capnography and by the increased use of portable difficult airway storage units.

A randomised trial of periprostatic local anaesthetic for transrectal biopsy

Increasingly transrectal ultrasound and biopsy is performed for the detection of prostate cancer. We have conducted a randomised trial to evaluate whether the addition of periprostatic local anaesthetic injection reduces the discomfort of the procedure. A total of 64 patients who attended a specialised prostate clinic and were being evaluated for an elevated prostate-specific antigen agreed to participate in the trial and were randomly allocated to two groups. The intervention group received 10 ml of 1% lignocaine in the periprostatic tissue prior to biopsy and the control group underwent a standard biopsy. All patients had a sextant biopsy under ultrasound guidance. After the procedure, they were asked to determine the severity of the pain on a scale of 0-10 and the whether the quality of the pain was mild, moderate or severe. The responses were distributed normally. The groups were compared using Student's t-test. Pain severity showed no significant difference between the two groups (P=0.14). There was a trend towards a statistical difference (P=0.07) on the qualitative pain scale. In conclusion, no significant difference in overall discomfort in men having sextant biopsies was detected between the two groups, suggesting that the administration of local anaesthetic may not be as valuable as early reports have suggested.

Development of a real-time RT-PCR assay for the detection of potato spindle tuber viroid

Potato spindle tuber viroid (PSTVd) is a quarantine pathogen in the European Union and causes damaging diseases of solanaceous crops. Under the EU Plant Health directive 2000/29/EC, countries must have the ability to detect and identify accurately and rapidly the introduction of harmful organisms in plants or plant products; furthermore, if the quarantine pathogen is found, be able to survey extensively for it. In this respect, PSTVd poses an interesting technical problem, since its RNA does not code for any proteins and thus any diagnostic method must be based on the detection of the RNA and be suitable for scaling up to testing large sample numbers. With this in mind a one-tube real-time RT-PCR assay based on TaqMan chemistry was developed. Investigations were carried out into various aspects of the assay relevant to the efficient amplification of targets that have a significant amount of secondary structure such as viroids. Thus comparisons were made of reverse transcription temperature, concentration and type of reverse transcriptase, RNA denaturation, sample purity and single versus two-tube reaction format. The assay developed was shown to be able to detect a wide range of isolates of PSTVd and in comparison with a chemi-luminescent hybridisation system was shown to be 1000-fold more sensitive. A further significant advantage of this assay format compared with hybridisation is that it is suitable for scaling up to large sample numbers using robotic liquid handling systems.

The influence of age on quality of life outcome in women following a tension-free vaginal tape procedure

PURPOSE

Tension-free vaginal tape (TVT) has been introduced and demonstrated to be an effective treatment for stress urinary incontinence. Improved general health in the elderly population has led to a greater number of patients seeking surgical treatment for incontinence. We evaluated the impact of TVT on quality of life in elderly patients, defined as age 70 and older.

MATERIALS AND METHODS

We prospectively evaluated 67 patients with genuine stress incontinence differentiated by age into 2 groups, namely 21 who were 70 years and older, and a control group of 46 younger than 70 years, with a validated questionnaire. We assessed quality of life changes following TVT for incontinence treatment.

RESULTS

At the most recent followup quality of life scores improved significantly in the 2 groups (p <0.05). Stress incontinence improved significantly in the 2 groups (p <0.05).

CONCLUSIONS

TVT is effective in each group. It is a viable treatment option to improve quality of life in older women with stress urinary incontinence.

Transgene delivery of plasmid DNA to smooth muscle cells and macrophages from a biostable polymer-coated stent

Metallic stents coated with a polyurethane emulsion containing plasmid DNA were implanted in rabbit iliac arteries to evaluate transgene delivery and expression in the vessel wall. The expression of the plasmid-encoded marker genes, beta-galactosidase, luciferase and green fluorescence protein (GFP), were evaluated at 7 days after implantation. In all cases, plasmid transfer was confined to the vessel wall at the site of stent implantation, plasmid DNA was not observed in vessel segments immediately proximal or distal to the stent and dissemination of plasmid DNA to lung, liver or spleen was not observed. Expression of transgenes occurred only in vessel segments in contact with the stent and analysis of the GFP expression pattern revealed a high frequency of marker protein-positive cells occurring at or near the luminal surface. The extent of transgene expression was dependent upon the quantity of DNA loaded onto the stent and no signal was detected in vessel segments that received polymer-coated stents lacking plasmid DNA. Of significance, colocalization studies identified transgene expression not only in vascular smooth muscle cells but also in macrophages. Hence, polymer-coated stents provide a new capability for transgene delivery to immune cells that are believed to contribute to the development of in-stent restenosis.

Distribution of vascular endothelial growth factor (VEGF) in prostate disease

Vascular endothelial growth factor (VEGF) is a heparin-binding polypeptide growth factor. It is a potent mitogen for endothelial cells. Immunohistochemical localisation of VEGF was performed on 25 moderate to poorly differentiated stage T4 M+ prostate cancer specimens and 30 benign prostatic hyperplasia (BPH) specimens. A positive result was indicated by area staining >25% and +2 or +3 staining intensity. Positive epithelial staining was observed in 50% of BPH specimens and 56% of cancer specimens, while positive stromal staining was observed in 73% of BPH specimens and 30% of cancer specimens. This may reflect an active role for stromal VEGF in the pathological process of BPH.

Detection of potato viruses using microarray technology: towards a generic method for plant viral disease diagnosis

Currently, most diagnostic methodology is geared towards detection of a very specific target species and often a number of assays need to be run in parallel to reach a result. The generic methods that are available for virus testing tends to give identification to the genus level only. The method described in this paper addresses this problem by exploiting a technology that has potential to test for a large number of targets in a single assay. Using the array constructed, the method was able to detect several common potato viruses (PVY, PVX, PVA, PVS) in single and mixed infections. The method was shown to be able to discriminate sequences with less than 80% sequence identity but was able to detect sequence variants with greater than 90% sequence identity. Thus the method should be useful for discriminating at the species level, but able to cope well with the intrinsic variability found within the genomes of RNA viruses. The sensitivity of the assay was found to be comparable with ELISA. The paper illustrates a significant step forward in the development of diagnostic methodologies by presenting for the first time a method that could theoretically be used not just for viruses, but for all the plant pathogens and pests that a modern diagnostic laboratory would want to test for, in a single completely generic and highly parallel format.

A comparison of the effectiveness of pre-hospital bag-valve-mask ventilation performed by Irish emergency medical technicians and anaesthetists working in a tertiary referral teaching hospital

The objective of this study was to assess the effectiveness of bag-valve-mask ventilation performed by emergency medical technicians with prehospital clinical responsibilities and to compare this with anaesthetists working clinically in tertiary referral teaching hospitals. Participants were asked to perform bag-valve-mask ventilation for three minutes on a Resusi Anne manniquin using a facemask and a two litre self inflating bag. The tidal volumes generated were quantified using a Laerdal skillmeter computer as grades 0-5 corresponding to 0, 335, 434, 561, 673 and > 800 mls. The effectiveness of bag-valve-mask (i.e. the proportion of ventilation attempts which achieved a tidal volume of > 434 mls) was greater for emergency medical technicians [88.2 (17.1)%] than for anaesthetists [40.4 (36.5)%] (P<0.001). Six of the 27 anaesthetists, but none of the 29 emergency medical technicians, were unable to produce even one effective tidal volume i.e. > 434 mls. It is likely that emergency medical technicians are able to perform adequate bag-valve-mask ventilation.

CARE: a framework for mental health practice

Much has been written about care and its centrality to nursing practice. Yet nursing theories and frameworks surrounding care have either been esoteric or prescriptive and are seen as irrelevant to practice. This paper problematizes the notion of care with a view to developing a clearer, flexible framework for mental health practice. The framework is the product of the authors' shared and individual experiences and theorizing as nurses and educators and has not yet been evaluated. The CARE framework (containment, awareness, resilience and engagement) is detailed, with examples of its use in practice. Using the framework offers a way for clinicians and carers to work more strategically with clients, helping them manage and understand their condition or disability, offering support to adapt and cope, and revealing and developing new or hidden strengths to help them endure the experience and find meaning for the recovery process. Taking up the framework within the everyday practice of mental healthcare offers several benefits for clients, clinicians and mental health.

An algorithm for the investigation and management of patients with suspected deep venous thrombosis at a district general hospital

The aim was to show that clinical assessment and serial Dopplers could be used to exclude deep venous thrombosis (DVT), and also that clinical assessment in combination with D-dimers could be used to exclude DVT. This was a prospective trial. Patients underwent clinical assessment, colour flow Doppler, and D-dimer measurement. Patients with an equivocal first Doppler and patients with a moderate/high pre-test clinical score had a repeat Doppler. Follow up information was obtained to see if further thromboembolism developed. Outcome measures included the reliability of the clinical assessment, Doppler, and D-dimer in excluding DVT. One hundred and ninety four patients were enrolled. The negative predictive value of a low medical pre-test score in excluding DVT was 92%. Eighty eight patients underwent D-dimer measurement. The negative predictive value of a D-dimer <400 units was 96%. The negative predictive value of a low clinical pre-test score and D-dimer <400 units was 100%. The negative predictive value of a low clinical pre-test score and D-dimer <800 units was 97%. The negative predictive value of the combination of a low clinical pre-test score and D-dimer <400 units was 100%. Twenty three per cent of patients had a low clinical pre-test score and D-dimer <400 units. Thus, a DVT could be excluded in 23% of referred patients. This information could be used to reduce Doppler requests by 23%. No patient in whom clinical assessment and serial Dopplers had excluded a DVT suffered further thromboembolism on follow up. This study has thus shown that a low medical pre-test score and negative Doppler reliably exclude DVT; a low pre-test score and negative D-dimer would reliably exclude DVT.

Systemic tissue inhibitor of metalloproteinase-1 gene delivery reduces neointimal hyperplasia in balloon-injured rat carotid artery

Metalloproteinases (MMP)-2 and MMP-9 play a role in smooth muscle cell (SMC) migration from the media to the intima following arterial injury. Intravenous administration of adenovirus encoding tissue inhibitor of metalloproteinase-1 (TIMP-1) into balloon-injured rat arteries (3 x 10(11) viral particles/rat; n=7) resulted in a transient expression of TIMP-1 and a significant inhibition of neointima thickening within 16 days ( approximately 40% vs. control; P=0.012). Three days after injury, the number of intimal SMCs was decreased by approximately 98% in TIMP-1-treated rats. However, no alteration was seen in intimal SMC proliferation after 13 days of injury. Therefore, our results show that systemic gene transfer of TIMP-1 is a promising approach in early restenosis treatment.